New LTC Survey Process Overview

1. New LTC Survey Process Overview November 28, 2017

2. Offsite Preparation • Team Coordinator (TC) completes offsite preparation • Repeat deficiencies • Results of last Standard survey • Complaints • FRIs (Facility Reported Incidences- federal only) • Variances/waivers • Necessary documents are printed

3. Offsite Preparation, continued • Unit and mandatory facility task assignments • Dining • Infection Control • Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review • Resident Council Meeting

4. Offsite Preparation, continued • Unit and facility task assignments, continued • Kitchen • Medication administration and storage • Sufficient and competent nurse staffing • QAA/QAPI • No offsite preparation meeting

5. Facility Entrance • Team Coordinator (TC) conducts an Entrance Conference • Updated entrance conference worksheet • Updated facility matrix • https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html • Brief visit to the kitchen • Surveyors go to assigned areas

6. Initial Pool Initial Pool Process • Surveyors screen all residents in their assigned area. • Conduct interviews, observations, and limited record review • ~8 residents/surveyor • Offsite, preselected residents • Residents identified onsite as a result of screens (prioritized by new admissions, vulnerable residents) • Facility Matrix used to identify other specific concerns(e.g., dialysis, hospice, smoking, ventilator, infection, etc.)

7. Resident Representative/Family Interviews • Non-interviewable residents • Familiar with the resident’s care • Complete at least three during initial pool process or early enough to follow up on concerns • Sampled residents if possible • Investigate further or no issue

8. Sample Sample size based on census (approximately 20% of census): • 70% offsite selected • 30% selected onsite by team: • Vulnerable • New Admission • Complaint • FRI (Facility Reported Incidents- federal only) • Identified concern

9. Sample • Complaints ~30% of standard surveys included complaints • Of surveys with complaints, 94% included no more than five complaint residents • Policy • States may add up to five residents associated with a complaint or FRI • If more than five residents are added to the sample, team size or survey time is extended

10. Investigations Investigations • All concerns for sample residents requiring further investigation • CE Pathways - https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html • Closed records • Facility tasks

11. Investigations • Majority of time spent observing and interviewing with relevant review of record to complete investigation • Use Appendix PP and critical elements (CE) pathways

12. Closed Record Reviews • Complete timely during the investigation portion of survey • Unexpected death, hospitalization, and community discharge last 90 days • System selected or discharged resident • Use Appendix PP and CE pathways

13. Dining – First Full Meal • Dining – observe first full meal • Cover all dining rooms and room trays • Observe enough to adequately identify concerns • If feasible, observe initial pool residents with weight loss • If concerns identified, observe another meal

14. Dining – Subsequent Meal, if Needed • Second meal observed if concerns noted • Use Appendix PP and CE Pathway for Dining • Dining task is completed outside any resident specific investigation into nutrition and/or weight loss

15. Infection Control • Throughout survey, all surveyors should observe for infection control • Assigned surveyor coordinates a review of influenza and pneumococcal vaccinations • Assigned surveyor reviews infection prevention and control, and antibiotic stewardship program

16. SNF Beneficiary Protection Notification Review • A new pathway has been developed • List of residents (home and in-facility) • Randomly select three residents • Facility completes new worksheet • Review worksheet and notices

17. Kitchen Observation • In addition to the brief kitchen observation upon entrance, conduct full kitchen investigation • Follow Appendix PP and Facility Task Pathway to complete kitchen investigation

18. Medication Administration Medication Administration • Recommend nurse or pharmacist • Include sample residents, if opportunity presents itself • Reconcile controlled medications if observed during medication administration • Observe different routes, units, and shifts • Observe 25 medication opportunities

19. Medication Storage Medication Storage • Observe half of medication storage rooms and half of medication carts • If issues, expand medication room/cart

20. Resident Council Meeting • Group interview with active members of the council • Complete early to ensure investigation if concerns identified • Refer to updated Pathway

21. Sufficient and Competent Nurse Staffing Review • Is a mandatory task, refer to revised Facility Task Pathway • Sufficient and competent staff • Throughout the survey, consider if staffing concerns can be linked to QOL and QOC concerns

22. Environment • Investigate specific concerns • Eliminate redundancy with LSC • Disaster and Emergency Preparedness • O2 storage • Generator

23. Team Meetings • Brief meeting at the end of each day • Workload • Coverage • Concern • Synchronize/share data (if needed)

24. Survey Team Composition • Survey time onsite is expected to be similar to current time spent onsite • Expect some lengthening while surveyors learn the new process • Number of surveyors and time onsite also impacted by other factors such as State licensure, facility history, or complaints • Continuous monitoring and dialogue

25. Available Training for Providers and the Public • National Calls and Q&As – Summer/Fall 2017 • Training available through ISTW • Specific provider training • Survey documents • Entrance worksheet • Facility Matrix • Procedure guide • Frequently Asked Questions

26. New Survey Process Websites • https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html • https://surveyortraining.cms.hhs.gov/index.aspx

27. Enforcement/5 Star • Phase II Enforcement: • Focus on education for phase II requirements (e.g., facility assessment, antibiotic stewardship, etc.) • Directed Plan of Correction, directed in-service training • Enforcement of Phase I requirements remains unchanged • Five Star Quality Rating System: • Surveys conducted using the new survey process not included in five star quality rating system • “Apples to Apples” comparison • Transparency and user-friendliness to consumers

28. Focused Surveys • Focused Surveys: • MDS surveys discontinued in FY’18 • Dementia surveys will continue by contractor

29. Updates • QCOR - focused on increased transparency and access to data, to providers, suppliers, and stakeholders https://qcor.cms.gov • Mandatory Imposition of Remedies – CMS reviewing; may be changes coming • CMPs – revised CMP tool resulting in per-instance CMPs for G level deficiencies